High Costs of Low Nursing Staff in Long-term Care Facilities

Low nurse-to-patient staffing practices impact healthcare in many ways. Studies have revealed a direct relationship between low nurse staffing and outcomes of both the nurses that work in this field and the patients that they serve. Harrington et al. explore the high costs related to low nurse staffing in nursing homes across the U.S., focusing on the need for improved staff ratios and the barriers preventing their implementation and enforcement. High patient-to-nurse ratios in long-term care facilities lead to poor patient outcomes and cost Medicare and Medicaid billions of dollars each year. Implementing and enforcing safe patient ratios that are based on the acuity of residents served is necessary to provide safe and effective holistic care in nursing homes across the U.S.

Background

For many years evidence has shown that nursing homes across the U.S. desperately need to make improvements. In 1987, the U.S. Congress passed the Nursing Home Reform Act in an attempt to address poor outcomes in long-term care facilities, included in this was a requirement for ‘sufficient staff.’ Since that time, many other initiatives aimed at improving care have been developed, including the Patient Protection and Affordable Care Act of 2010. According to Harrington et al., “These efforts have included revisions in policies and survey procedures, public reporting of nursing home quality, and other efforts that have resulted in some positive changes in nursing home care, such as reductions in the use of physical restraints”. However, despite these changes studies continue to show major deficits in nursing home care leading to poor patient outcomes and increased healthcare costs.

Results of a recent study conducted by the U.S. Office of the Inspector General “found that 33% of Medicare nursing home resident sample experienced adverse events, resulting in harm or death during the first 35 days of post-acute skilled nursing stay”. Skilled healthcare professionals could have prevented over half of these adverse events with proper monitoring and care, and could have saved Medicare 2.8 billion dollars.

As the requirements set by the Nursing Home Reform act in 1987 for ‘sufficient’ staffing continue to prove inadequate, 41 states have since raised their staffing requirements above that set by the federal government. Despite these changes, staffing standards continue to fall short. As advancements continue in medicine, life expectancy and acuity of patients rise, leading to an increased need for more skilled nursing staff to monitor and care for those in need. Thus, the implementation and enforcement of safe staffing ratios must also take patient acuity into consideration.

Impact on Nursing

Having an adequate number of skilled nurses working on the floor, monitoring patients, and overseeing the care provided, improves healthcare outcomes in many ways. In addition to poor patient outcomes and higher costs, low staffing can affect morale, lead to job dissatisfaction, and high turnover rates. Harrington et al. state, “It is likely that adequate staffing levels must be addressed before improvements can be made in other factors such as turnover, management, and competency”. The issue of adequate staffing is central to improvements in healthcare and nursing so much so that staffing levels can be used as a predictor of nursing home deficiencies and hospitalization rates. Despite this knowledge, when the Centers for Medicaid and Medicare Services created a model for determining minimum staff levels with consideration for resident acuity and compared that number to actual staffing practices, it was revealed that nearly 60% of facilities did not meet the total staff minimum standard, nearly 80% did not meet RN minimum standards, and 54% did not meet minimum standards for nursing assistants.

With all this evidence to support higher nurse-to-patient ratios, one would think the solution is simple. Yet the problem remains. Studies have shown that the best way to improve staffing ratios is through federal and state implementation. According to Harrington et al., “higher state minimum RN and total nurse staffing have been shown to have a stronger effect on nursing home staffing levels than higher Medicaid payment rates”. This is likely due to the fact that there is little to no regulation on how nursing homes spend their profits, and staffing ratios do not influence payments made by Medicare and Medicaid which both focus on cost control rather than the quality of outcomes. According to Harrington et al., for-profit nursing homes make up about 70% of all facilities operating in the U.S., and with the goal of maximizing profits, often operate with lower staff than non-profit facilities. As one would imagine, these for-profit facilities also have more violations and poorer patient outcomes. Market-based strategies aimed at increasing public disclosure and reporting have been implemented in an effort to combat this issue but have had little success showing again that regulatory requirements may be the most effective way to improve staffing ratios and quality outcomes.

The CMS, the agency responsible for federal regulation and standard setting, works with other state agencies to ensure facility compliance. Investigations of completed surveys by these agencies have revealed violations are often under-identified and/or underrated, and penalties are minimized or not issued at all. In addition, Medicare and Medicaid rarely deny facilities access to their program based on violations, leaving little to no incentive for facilities to remain compliant. Even if regulations were being enforced appropriately, the CMS has no guidelines regarding low or inadequate staffing penalties.

Other factors influencing this issue include the divide between liberal political leadership, which is linked to stronger regulation, and conservative political leadership that favors less government intervention. Additionally, nursing home associations and industries have donated money to political campaigns that lend to their interest. One such example is The Kentucky nursing home industry which gave a substantial amount of money to politicians “while lobbying against bills requiring them to hire more employees, increasing fines for violations, and prosecuting elder abuse”. Another factor is the government tends to hire industry managers that may have more conservative views that tend to favor less regulation.

Solutions to this issue are quite complicated and are influenced by many factors. According to Harrington et al., “Economic, regulatory, and political solutions are needed to ensure that all nursing homes provide safe and high-quality of care”. Though the path to solving this issue faces many obstacles, it seems to be heavily paved onto the hands of state and federal regulatory agencies such as the CMS. These regulatory agencies need to not only implement safe staffing ratios, but they need to enforce them. Regulating agencies, as well as nursing homes, need to be held accountable for their role in promoting or preventing quality care outcomes. Additionally, Medicare and Medicaid payments should be linked to outcomes rather than focused on cost-effectiveness. Better incentives should be implemented for having more skilled staff. If steps are not taken to improve staffing in nursing homes, quality care outcomes will continue to fall and patients, as well as the nurses that serve them, will also continue to suffer.

Conclusion

The cost incurred by low or inadequate nurse staffing is far too high, both financially and from a health perspective. Nurses and residents suffer the consequences of nursing home leaders choosing the bottom line over sufficient staffing and quality outcomes. Barriers that must be overcome include issues in economics, regulatory agencies and policies, and politics. Implementation and enforcement of higher staff-to-patient ratios that include resident acuity are vital to safe and effective nursing care in nursing homes across the U.S.